Survey: ‘Heart-brain clinics’ useful policy to assess cognitive decline for people with HF
Key takeaways:
- Survey data show most cardiologists do not screen patients with HF for cognitive impairment.
- Respondents cited lack of training and time and were open to a multidisciplinary screening framework.
Data from a survey conducted in the Netherlands show most cardiologists do not routinely screen for cognitive impairment in older patients with HF, but they were open to the idea of a dedicated “heart-brain clinic” to give such full care.
“In current HF guidelines, cognitive impairment is addressed as a risk factor for poorer self‐care and significant adjustments in HF treatment plans is recommended in the event of dementia,” Charlotte M. Nijskens, MD, PhD, of the department of internal medicine, geriatrics section, at Amsterdam University Medical Centers, and colleagues wrote in Clinical Cardiology. “However, these guidelines lack practical instructions on which patients need to be screened and the timing of screening, which hinders the provision of tailored care. Although the American Heart Association gives some examples of tools for cognitive screening, they do not recommend how and when to use these tools. This gap in clinical recommendations most likely leads to cases of significant cognitive impairment going unnoticed in current clinical practice.”
Image: Adobe Stock
Nijskens and colleagues distributed an online survey to 55 cardiologists from the Dutch working groups on Geriatric Cardiology and Heart Failure. The mean age of respondents was 48 years and 62% had more than 10 years of experience in the treatment of HF. The survey included 20 multiple choice questions and two open-ended questions about current clinical practice, the impact of cognitive impairment on clinical decision‐making and the knowledge and skills needed to recognize cognitive impairment.
Of the 36 cardiologists who responded to the survey, just 3% performed structured cognitive screening, whereas 83% stated that not enough attention is paid to cognitive impairment. The researchers noted that respondents generally underestimated the prevalence of cognitive impairment, with only 25% estimating the correct prevalence of 20% to 40%. One in three cardiologists regularly referred their patients to the geriatrician or neurologist for cognitive analysis.
The survey also showed that 53% of respondents indicated not being educated on cognitive problems in patients with HF or chronic cardiac conditions during their specialty training. Only 8% indicated that recognizing cognitive impairment in cardiac patients was their responsibility; most considered it the responsibility of geriatricians (14%) or primary care physicians (47%).
Most participants (77%) did not consider it feasible to pay more attention to cognition within cardiac care, indicating a “desire for a clear protocol” and having too little knowledge about the condition. Eighty percent agreed that systematic cognitive screening would benefit their patients and 74% wished to implement a heart-brain clinic.
Heart-brain clinic setup
The researchers outlined a stepwise screening program for cognitive impairment in all patients with HF, based on the first heart-brain clinic opened in 2022 in the Amsterdam UMC. At that outpatient cardiology clinic, all patients aged 60 years or older are screened for a history of delirium, cognitive complaints and frailty with the Edmonton Frail Scale; nurses are trained for 1 hour to perform this screening.
“Once this screening is incorporated in clinical routine, it takes only 5 minutes to perform during one of the earlier outpatient visits,” the researchers wrote. “When patients are considered to be frail and at increased risk for cognitive impairment, a stepwise program is provided including geriatric assessment, medication review, and exploration of treatment goals.”
The geriatric assessment that may follow includes tests of muscle strength, the Mini Nutritional Assessment-Short Form, Mini‐Mental State Examination, Montreal Cognitive Assessment and the Geriatric Depression Scale.
“In the event of suspected cognitive impairment, an extensive cognitive analysis is performed, including neuropsychological examination and brain MRI,” the researchers wrote. “Results are discussed and diagnoses are made in a multidisciplinary consensus meeting.”
The clinic focuses on personalized medical treatment, including deprescribing, supportive care, optimization of home care and advance care planning.
“Depending on the diagnosis, patients remain under the care of the cardiologist or of the (internist‐)geriatrician as well,” the researchers wrote.
Need for multidisciplinary care
The researchers noted that only cardiologists from the working groups on geriatric cardiology and HF participated in the survey, adding that such respondents are likely more aware of cognitive impairment in people with HF than cardiologists who mainly treat younger patients.
“We therefore may have overestimated cardiologists’ knowledge about cognitive screening and the implications for HF treatment,” the researchers wrote. “However, this possibility emphasizes the need for multidisciplinary heart-brain clinics even further. In these clinics, structural screening takes place even without the involvement of a cardiologist who might be unaware of cognitive impairment in his patients.”
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